<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
        <center><font size="10px" face="segoe print" color="Blue"><b>Registration Form</b></font></center>
		<title>Form Table</title>
                <style type="text/css">
                    body{
                        color:#0000aa;
                        font-style:italic;
                        background:#aaaaee;
                       
                        }
                    td{
                        color:#00ae0f;
                        font-family: chiller;
                        text-align:justify;
                        font-size: 15pt;
                        }
                        input{
                            background: #bbccbb;
                        }
                </style>

	</head>
		<body>
                    <center><form method="GET" action="<?php echo $_SERVER['print.php'];?>">
				<table border="0" cellspacing="2">
					<tr>
						<td colspan="4">
						<input type="radio" name="prefix" value="Mr."/>Mr.
						<input type="radio" name="prefix" value="Mrs."/>Mrs.
						<input type="radio" name="prefix" value="Ms."/>Ms.
						</td>
					</tr>
					<tr>
						<td>Name</td>
						<td><input type="text" name="first" value="First..."></td>
						<td><input type="text" name="middle" value="Middle...(blank if not)"></td>
						<td><input type="text" name="last" value="Last..."></td>
					</tr>
					<tr>
						<td>Address(per.)</td>
						<td><input type="text" name="city" value="City..."></td>
						<td><input type="text" name="province" value="Province..."></td>
						<td><input type="text" name="country" value="Country..."></td>
					</tr>
					<tr>
						<td>Address(temp.)</td>
						<td><input type="text" name="city1" value="City..."></td>
						<td><input type="text" name="province1" value="Province..."></td>
						<td><input type="text" name="coountry1" value="Country..."></td>
					</tr>
					<tr>
						<td>Birth Date</td>
						<td><select name="day">
						<option>01</option><option>02</option><option>03</option><option>04</option><option>05</option>
						<option>06</option><option>07</option><option>08</option><option>09</option><option>10</option><option>11</option>
						<option>12</option><option>13</option><option>14</option><option>15</option><option>16</option><option>17</option>
						<option>18</option><option>19</option><option>20</option><option>21</option><option>22</option><option>23</option>
						<option>24</option><option>25</option><option>26</option><option>27</option><option>28</option><option>29</option><option>30</option>
						<option>31</option>
						</select></td>
						<td><select name="month">
						<option>Januray</option><option>February</option><option>March</option><option>April</option><option>May</option>
						<option>June</option><option>July</option><option>August</option><option>September</option><option>October</option><option>November</option>
						<option>December</option>
						</select></td>
						<td><input type="text" name="year" value="1985"></td>
					</tr>
					<tr>
						<td>Education</td>
						<td colspan="3">
							<table border="0" width="100%">
								<tr>
								<td width="15%"><input type="radio" name="edu">SLC</td>
								<td width="30%"><input type="radio" name="edu">+2/Intermediate</td>
								<td width="20%"><input type="radio" name="edu">Bachelor</td>
								<td width="20%"><input type="radio" name="edu">Masters</td>
								<td width="15%"><input type="radio" name="edu">PHD</td>
								</tr>
							</table>
						</td>
					<tr>
						<td>Nationality</td>
						<td><select name="nationality">
						<option>America</option><option>Argentina</option><option>Bangladesh</option><option>Bhutan</option><option>Canada</option>
						<option>China</option><option>Denmark</option><option>England</option><option>Ghana</option><option>India</option><option>Indonesia</option>
						<option>Nepal</option><option>Pakistan</option><option>Srilanka</option><option>Taiwan</option><option>Uganda</option><option>Others</option>
						</select></td>
						<td colspan="2">Citizenship No&nbsp;<input type="text" name="ctzn" size="32"></td>
					</tr>
					<tr>
						<td>Language</td>
						<td colspan="3">
							<table border="0" width="100%">
								<tr>
									<td width="21%"><input type="checkbox" name="lang[]" value="Nep">Nepali</td>
									<td width="31%"><input type="checkbox" name="lang[]" value="Newar">Nepal Bhasa</td>
									<td width="23%"><input type="checkbox" name="lang[]" value="Eng">English</td>
									<td width="25%" align="right"><input type="text" name="lang" value="others..Specify.."></td>
								</tr>
							</table>
						</td>
						</tr>
					<tr>
						<td>Contact</td>
						<td><input type="text" name="cell" value="Cell no.(blank if not)"></td>
						<td><input type="text" name="home" value="Home no.(blank if not)"></td>
						<td><input type="text" name="office" value="Office no.(blank if not)"></td>
					</tr>
					<tr>
						<td>E-m@il</td>
						<td colspan="3">
							<table>
								<tr>
									<td><input type="text" value="Primary@domain.com" name="primary"size="34"></td>
									<td><input type="text" value="Secondary@domain.com(blank if not)" name="secondary"size="34"></td>
								</tr>
							</table>
						</td>
					</tr>
					<tr>
						<td>Desired Username</td><td><input type="text" size="20" name="username"></td>
						<td><input type="button" value="Availability">&nbsp;&nbsp;&nbsp;&nbsp;Password</td><td><input type="password" size="20" name="password"></td>
					</tr>
				</table>
						<br/><input type="submit" name="submit" value="Register" title="Click to Submit">&nbsp;&nbsp;&nbsp;<input type="reset" name="reset" value="Cancel" title="Click to reset">
			
                                <?php
                                    $submit     = $_GET['submit'];
                                    $sex        = $_GET['prefix'];
                                    $name1      = $_GET['first'];
                                    $name2      = $_GET['middle'];
                                    $name3      = $_GET['last'];
                                    $ct         = $_GET['city'];
                                    $prov       = $_GET['province'];
                                    $cntry      = $_GET['country'];
                                    $day        = $_GET['day'];
                                    $mnth       = $_GET['month'];
                                    $yr         = $_GET['year'];
                                    $edu        = $_GET['edu'];
                                    $nation     = $_GET['nationality'];
                                    $ctzn       = $_GET['ctzn'];
                                    $lang       = $_GET['lang'];
                                    $cell       = $_GET['cell'];
                                    $home       = $_GET['home'];
                                    $office     = $_GET['office'];
                                    $mail1      = $_GET['primary'];
                                    $mail2      = $_GET['secondary'];
                                    $user       = $_GET['username'];
                                    $pass       = $_GET['password'];

                                    if($submit !="" && $user !="" && $pass !="" && $name1 !="" && $name3 !="")
                                        {
                                        echo "<br/>The data you inserted is below</br>";
                                        echo "Your name is $sex $name1 $name2 $name3<br/>";
                                        echo "You live in $ct city,$prov province $cntry<br/>";
                                        echo "You were born on $day-$mnth-$yr<br/>";
                                        echo "Your education qualification is $edu<br/>";
                                        echo "Your Citizenship No. is $ctzn of $nation<br/>";
                                        echo "language you work on is $lang<br/>";
                                        echo "Your contact nos. are CELl:$cell  Home:$home  Office:$office<br/>";
                                        echo "Your email ID Primary :$mail1  Secondary : $mail2<br/>";
                                        echo "Your desired Username : $user<br/>";
                                        echo "Your Password : $pass";
                                        }
                                    else
                                        echo "<br/>Please, Provide minimum data required";
                                    ?>

			</form></center>
		</body>
</html>


